Is goal-directed fluid therapy based on dynamic variables alone sufficient to improve clinical outcomes among patients undergoing surgery? A meta-analysis

Abstract

BackgroundWhether goal-directed fluid therapy based on dynamic predictors of fluid responsiveness (GDFTdyn) alone improves clinical outcomes in comparison with standard fluid therapy among patients undergoing surgery remains unclear.MethodsPubMed, EMBASE, the Cochrane Library and ClinicalTrials.gov were searched for relevant studies. Studies comparing the effects of GDFTdyn with that of standard fluid therapy on clinical outcomes among adult patients undergoing surgery were considered eligible. Two analyses were performed separately: GDFTdyn alone versus standard fluid therapy and GDFTdyn with other optimization goals versus standard fluid therapy. The primary outcomes were short-term mortality and overall morbidity, while the secondary outcomes were serum lactate concentration, organ-specific morbidity, and length of stay in the intensive care unit (ICU) and in hospital.ResultsWe included 37 studies with 2910 patients. Although GDFTdyn alone lowered serum lactate concentration (mean difference (MD) − 0.21 mmol/L, 95% confidence interval (CI) (− 0.39, − 0.03), P = 0.02), no significant difference was found between groups in short-term mortality (odds ratio (OR) 0.85, 95% CI (0.32, 2.24), P = 0.74), overall morbidity (OR 1.03, 95% CI (0.31, 3.37), P = 0.97), organ-specific morbidity, or length of stay in the ICU and in hospital. Analysis of trials involving the combination of GDFTdyn and other optimization goals (mainly cardiac output (CO) or cardiac index (CIx)) showed a significant reduction in short-term mortality (OR 0.45, 95% CI (0.24, 0.85), P = 0.01), overall morbidity (OR 0.41, 95% CI (0.28, 0.58), P < 0.00001), serum lactate concentration (MD − 0.60 mmol/L, 95% CI (− 1.04, − 0.15), P = 0.009), cardiopulmonary complications (cardiac arrhythmia (OR 0.58, 95% CI (0.37, 0.92), P = 0.02), myocardial infarction (OR 0.35, 95% CI (0.16, 0.76), P = 0.008), heart failure/cardiovascular dysfunction (OR 0.31, 95% CI (0.14, 0.67), P = 0.003), acute lung injury/acute respiratory distress syndrome (OR 0.13, 95% CI (0.02, 0.74), P = 0.02), pneumonia (OR 0.4, 95% CI (0.24, 0.65), P = 0.0002)), length of stay in the ICU (MD − 0.77 days, 95% CI (− 1.07, − 0.46), P < 0.00001) and in hospital (MD − 1.18 days, 95% CI (− 1.90, − 0.46), P = 0.001).ConclusionsIt was not the optimization of fluid responsiveness by GDFTdyn alone but rather the optimization of tissue and organ perfusion by GDFTdyn and other optimization goals that benefited patients undergoing surgery. Patients managed with the combination of GDFTdyn and CO/CI goals might derive most benefit.Electronic supplementary materialThe online version of this article (10.1186/s13054-018-2251-2) contains supplementary material, which is available to authorized users.

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“…Static preload indices such as central venous pressure are not su cient to assess uid responsiveness (2) whereas dynamic preload indices such as pulse pressure variation (PPV) and stroke volume (SV) variation have been used successfully. (3) However, such indices suffer from several limitations and should be used only under strict conditions. (4) Alternative dynamic methods of assessment such as lung recruitment maneuvers (LRM) have been developed.…”

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“…There is quite strong evidence to support the benefits of GDFT in high-risk patients undergoing major surgical procedures [ 9 , 11 ]. Indeed, over the past 15 years, several meta-analyses of the impact of GDFT in patients undergoing moderate and high-risk surgeries have observed that GDFT improves outcome compared with routine care [ 8 , 11 , 17 – 20 ]. However, the studies included in these meta-analyses are highly heterogeneous, with different protocols, different physiologic endpoints, and different technologies to measure stroke volume and cardiac output.…”

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“…Thus, compared with open abdominal surgery, the risk of respiratory failure, ARDS, pulmonary infections, and pulmonary embolism can be reduced by applying a laparoscopic approach [94]. Perioperative fluid therapy and transfusion can also trigger postoperative ARDS; therefore, a restrictive goal-directed fluid strategy should be considered for patients with high risk of PPC [95,96]. Volatile anesthetics have lung-protective potential and can improve the surgical outcome as well [97].…”